I attended the annual conference of the leading TMJ/Craniofacial pain organization this past month in which I hold a Fellowship status (AACP). After hours, I was able to spend more time with friends and mentors, often we learn as much sharing ideas and techniques as in the actual conference.
There is an increasing awareness and focus on the importance of proper nasal breathing, management of sleep disordered breathing problems such as Sleep Apnea, subtler Upper Airway Resistance Syndrome (typically in women who have poor sleep and excess fatigue without snoring or obvious apnea) and sleep breathing signs/symptoms and effects on growing children that are often missed. I am Board Certified in Dental Sleep Medicine by the American Academy of Craniofacial Dental Sleep Medicine.
Later this summer, I’ll be attending a similar conference with another organization I hold a Mastership status in (ICCMO) and look forward to spending time with those colleagues, many of which are the same experts.
I look forward to expanding my knowledge base, clinical tips and techniques, and comparing notes with my friends who are also leaders in the field of TMJ and Dental Sleep Medicine.
Have you ever had a coach or a trainer tell you to breathe in through your nose instead of your mouth? There are scientific facts that prove nose breathing is better for you.
Optimal oxygen exchange occurs when we breathe through our nose versus the mouth. You get more than 30% more oxygen with each breath taking a breath through the nose. It also causes the release of “calming” neurochemistry in the brain and body.
It’s interesting that a single, slow nasal breath exposes us to more of the surrounding atmosphere than our skin. It’s estimated that our skin is about 3 square meters if layed out as a sheet- exposed to the air and environment. The volume of “skin” inside the lungs is estimated to be 50-100 square meters if laid out as a sheet. The total surface area of all the little “air sacs” that fit in the lungs is amazing.
Breathing through the nose (instead of the mouth) warms, moistens, and somewhat cleans the air as it swirls through the nasal passages. It’s “cleaner air”.
Mouth breathing doesn’t moisten much, filter, or deliver as much oxygen as a single breathe through the nose.
If you find it hard to breathe through the nose for 10 minutes, practice if throughout the day. It will get easier as the nasal tissues re-adapt to airflow.
Is asymptomatic the same as “normal” and is “No pain, No problem” the standard of TMJ care today?
Many chronic conditions such as hypertension, diabetes, heart disease, arthritis and neck problems go on for years without pain or notable symptoms by patients. TMJ dysfunction is also a progressive, measurable problem that ultimately leads to muscle or joint pain, bite issues, tooth fracture and loss, headaches, ear pain, dizziness, among other head and neck symptoms.
In medicine, it has become standard to consider chronic, measurable joint damage as “normal” only because it isn’t painful. There are many reasons this has come to be the norm and is accepted. Early intervention is better than almost all attempts to manage advanced bone and joint disease, especially the TMJ.
We know that infants that have short lingual frenum’s (tongue tied) don’t nurse well, have more problems eating as teeth erupt, and have altered jaw growth. Likewise, early allergies to foods and environmental triggers can enlarge the tonsil tissue in the nose and throat. This leads to a cascade of growth distortions throughout the maxilla, mandible, and TMJ that strongly influence the onset of TMJ misalignment, damage and dysfunction over time.
Crooked teeth are the initial sign (not symptom) that growth has been negatively affected. Straightening the teeth with braces may or may not correct an underlying TMJ problem. Sometimes the TMJ becomes symptomatic as orthodontics begins to move teeth that have an unstable jaw joint. Over our life, the adaptive systems change in response to direct injury, growth disturbances, and small or large injuries throughout the body. This is adaptation. As our adaptive capacities change over time, the compensation may be exceeded and pain or altered movement becomes noticed. One respected TMJ author (McNeill) estimates that 75% of the population may experience signs of TMJ/masticatory problems.
A study this year (2018) assessed the Temporomandibular Joints (TMJ’s ) of 186 randomly selected people between ages of 18-21 that had no symptoms of a TMJ problem or an obvious bite problem found upon closer evaluation that 33.4% of the TMJ’s examined had early stretching/damage to the TMJ ligaments. 8% showed incomplete disc displacement and 5% had discs that fully displaced. None had symptoms based on current dental misconceptions of TMJ dysfunction.
The earlier children are screened by a TMJ expert the better the opportunity to guide growth through non-surgical orthotic treatment as they progress through orthodontics or as a general risk assessment as they approach the teenage years. This can help avoid more complex damage to the TMJ, and less effective therapy if intercepted earlier and growth is redirected back towards heath of the jaws and TMJ together.
 Assessment of the Temporomandibular Joint Function in young adults without complaints from the masticatory system: International Journal of Medical Sciences, 2018;15(2). Kondrat, Sierpinska, Radke.
Children don’t have “sleep apnea”; they have Sleep Disordered Breathing that will progress into Obstructive Sleep Apnea as an adult unless the craniofacial growth disturbances from childhood breathing problems are corrected.
TOP 10 Common Symptoms of Sleep Disordered Breathing in Children:
Snoring, loud or labored Breathing.
Even 1X per week in young children is considered pathologic
Habitual mouth breathing, or signs of it
Unable to nasal breath for several minutes
Nighttime bruxing, dental signs of bruxing if not observed
Restless Sleep: tossing and turning, kicking the wall, find them twisted in sheets in am.
Poor attention span, constantly moving, fidgety
Scalloped tongue/depressed curve of spee (bicuspid drop), tongue rests over posterior teeth or has lateral/anterior scalloping on tongue.
Narrow and/or high arched palate
Visible tonsils grade 1+ or more.
Allergic shiners, glazed/watery eyes
Sensitive gag reflex or guarding of the airway
Problems swallowing water (forced swallow) problems chewing dry or chewy foods
Most of us have experienced a sharp “zing” in a tooth while chewing or biting something hard like ice, candy, or a popcorn kernel. That sudden “zing” causes our jaw muscles to instantly stop contracting and activate the jaw opening muscles unconsciously. That reflex is one of the strongest in the body and is part of a protection of the mouth – being a means of survival by eating, breathing, and speaking.
The zing in our teeth is a small fracture that either injures the tooth nerve or flexes the tooth (yes, teeth can flex just like steel) which irritates the nerve. It takes a tremendous amount of force to crack an intact tooth (one without a filling). Cracked teeth are typically painful/sensitive to cold (81%). Pain with biting down (intermittently) is the second most common symptom (35%) of a cracked tooth and spontaneous pain (28%) is the third symptom of a cracked tooth according to a study in the Journal of Dentistry Dec 28, 2017. Cracks can be difficult to find and repair. Sometimes the tooth requires a crown and/or root canal.
What can cause a tooth to crack?
Sometimes we can crack teeth from bruxing or clenching. These unconscious forces often happen during sleep when our reflexes aren’t fully intact to protect the teeth. Teeth with fillings of varying size are more prone to fracture while chewing or clenching/grinding at night.
2/3rds of patients report cracked teeth were from grinding or clenching at night, the study reports. Nighttime clenching/grinding are one of the most common signs of a Sleep Breathing Disorder such as sleep apnea or some of the variant sleep breathing disorders. Activating the jaw closing muscles during clenching or bruxing stiffens the airway and can quickly open it during an apnea (airway closure while sleeping) event or hypopnea (partial closing).
If you clench your teeth or have cracked teeth from clenching your dentist probably made you a nightguard to protect the teeth. Nightguards have been shown in studies (previously written about this) to worsen sleep breathing disorders thereby increase clenching and bruxing (grinding teeth). If you have cracked teeth, wear a nightguard and find you bite harder on that than without, you are likely to have an underlying sleep breathing disorder that is causing the clenching and grinding.
Another article appeared showing the physical and mental/developmental effects of too little sleep for all of us, but especially kids. Sleep Organizations are pushing for later start times for school based on the growing body of evidence “short sleep” is affecting health.
Parents can model better sleep habits and set some simple guidelines for their children’s sleep, such as a media curfew and a central place all devices are kept overnight.
Our children aren’t getting enough sleep and it will affect their school performance and health. Between sports after school, homework and having to get up early – middle school and high school kids are sleep deprived. Another significant factor is access to social media in their bedrooms that can keep them up late.
This study re-iterated the known physical and mental health effects of insufficient sleep. Brain development up through late teen years and processing of the day’s learning requires hours of time every night or, every few nights on a consistent basis. This ensures the body has proper sleep staging for growth and repair of the body itself, the brain also needs specific time and sleep staging to process that days input, link it to other data, and process emotional input.
Prevalence of short sleep duration* on an average school night among high school students, by state — Youth Risk Behavior Survey, 2015
Insufficient sleep among children and adolescents is associated with increased risk for obesity, diabetes, injuries, poor mental health, attention and behavior problems, and poor academic performance. The American Academy of Sleep Medicine has recommended that, for optimal health:
Children aged 6–12 years should regularly sleep 9–12 hours per 24 hours.
Teens aged 13–18 years should sleep 8–10 hours per 24 hours.
CDC analyzed data from the 2015 national, state, and large urban school district Youth Risk Behavior Surveys (YRBSs) to determine the prevalence of short sleep duration among middle school students was 57.8%, with state-level estimates ranging from 50.2% (New Mexico) to 64.7% (Kentucky). The prevalence of short sleep duration among high school students in the national YRBS was 72.7%.
To ensure their children get enough sleep, parents can support the practice of good sleep habits. One important habit is maintaining a consistent sleep schedule during the school week and weekends. Parent-set bedtimes have been linked to getting enough sleep among adolescents.
Evening light exposure and technology use are also associated with less sleep among adolescents. Parents can limit children’s permitted use of electronic devices in terms of time (e.g., only before a specific time, sometimes referred to as a “media curfew”) and place (e.g., not in their child’s bedroom).
Wheaton AG, Jones SE, Cooper AC, Croft JB. Short Sleep Duration Among Middle School and High School Students — United States, 2015. MMWR Morb Mortal Wkly Rep 2018;67:85–90. DOI: http://dx.doi.org/10.15585/mmwr.mm6703a1
Snoring, sleep disordered breathing and sleep apnea in children is associated with impaired attention, neurocognitive deficits and poor academic performance that is measurable in third grade children.
Children should not snore when sleeping, at any age. Snoring even 1-2 nights per week indicates a potential sleep apnea disorder. Other signs are bedwetting (consistent), restless sleep (they move and thrash throughout the night), ADD/ADHD-like behavior and resistance going to sleep – to name a few more common symptoms.
Some signs and symptoms that are warning are obviously enlarged tonsils (if you can see them they are probably too large, despite what the pediatrician may say), front teeth that don’t close (open bite), retruded jaws. Dentists trained on TMJ and sleep disorders can evaluate children quickly by a history and clinical examination. Additional testing can provide a diagnosis.
In the study mentioned, snoring “always” was significantly associated with poor academic performance in math, science and spelling. This relationship was also seen in children who snored, but who didn’t have hypoxia (low oxygen at night).
When evaluating children (up to age 16) the adult criteria cannot be used. Children suffer negative effects in jaw growth, cognitive performance and TMJ problems that often arise because of a distortion in jaw growth. The effects of a sleep disorder in children affect growth of the mouth and face, which worsens the airway. Normal measurements of oxygen, apnea (stopping breathing), must be far more sensitive for children due to the effects on growth. These changes are notable clinically and on cephalometric images.
Fortunately, today we have better clinical evaluations based on research, non-radiographic soundwave analysis of the airway and 3D airway imaging of tonsils/adenoids that make restrictions easy to see.
If identified early enough, removal of enlarged tonsils and adenoids can reverse the effects caused by your child not being able to breathe well; in one study 77% of open bites and about 60% of crossbites self-corrected after removing airway blockages from tonsils and adenoids
If your grade schooler or middle school child snores, has headaches, TMJ noises or sleeps poorly it would be beneficial to have them evaluated at our office for a potential sleep disorder. We will work with a physician to get a proper diagnosis and course of treatment using our knowledge of dental-facial growth, anatomy and make sure the airway is clear.
 Am. J Respir Crit Care Med. 2003, Aug 15:168(4)
 Craniofacial differences according to AHI scores of children with OSA: cephalometric study of 39 patients
 Int J Pediatr Otorhinolaryn. 1991 Sep;22(2). Influence of tonsillar obstruction and tonsillectomy on facial growth and dental arch morphology
A recent article in J. Orofacial Pain & Headache, (the Journal of the American Board of Orofacial Pain of which I am a Diplomat) reviewed success rates of treating TMJ problems by Occlusal Adjustment (also called Equilibration of teeth). Occlusal Adjustment was the final treatment after the Dentists initially used a nightguard, then a splint. Neither treatment helped the pain complaints of headache or facial pain. As a final effort to alleviate the symptoms the Dentists decided to equilibrate the teeth because, as the article suggests, “they didn’t know what else to do”. This was reported to have been done despite the dentist’s foreknowledge that equilibration had a low success rate in alleviating TMJ symptoms.
In the American Academy of Sleep Medicine this abstract was included in one of the “most Popular” from last year and it was worth reminding parents of children. The article reviewed the relationship of children, nighttime bruxism (grinding/popping teeth) and preschool behavior problems.
Preschool children who grind their teeth and are withdrawn have lower school performance. This article in the Journal of the American Academy of Sleep Medicine was one of last year’s most popular topics for a good reason.
The study had just over 1500 preschool aged children enrolled. It asked whether the kids snored and then had observations from the parents that indicated the children who snored were more withdrawn, didn’t get involved with other children and had trouble adjusting to preschool. The more days per week these preschool children snored (starting at 1 day – up to 4 days) the observed negative behaviors increased. Interestingly these behaviors started presenting as the front teeth began to grow in (this is when the negative growth and physiologic effects of large tonsils/adenoids become problematic from a TMJ and Dental Sleep medicine specialist).
The article advises that preschool children get 11-13 hours of sleep (which is normal at this age – many parents are surprised at how much sleep kids need), it also mentions stress as a “possible” factor.
Suggestions from both Dental and Medical Sleep Specialists for children as bedtime approaches are universal; have a set bedtime and allow 30 minutes to “wind down”. No electronics of any kind for 30 minutes prior to bed. Interact with your children in a non-stimulating way as they wind down – read to them, etc. In our hectic schedules this can be hard to start, but once it’s established (may take a couple weeks or so of patient but hard work to establish the routine) it gives parents extra time to also wind down after their kids are asleep earlier!
From Dental Sleep Medicine and TMJ perspectives, this article is based on the fails to address the most important reasons early childhood bruxing occurs; large tonsils and adenoids that restrict breathing while kids sleep. This is Sleep Apnea and is directly correlated to behavior problems in children, lower academic performance, and ADD/ADHD-like behavior. These correlations are well documented in the Dental Sleep literature as well as the American Academy of Sleep Medicine journals. Evaluation by a Dentist trained in Dental Sleep Medicine and TMJ/growth for airway obstruction and altered facial development is recommended.
Facial growth is also recognized with infants who are “tongue tied” because they don’t nurse well. Many pediatric dentists are beginning to evaluate this critical anatomic problem – treatment is easy and fast to “free the tongue”. Myofunctional and Speech therapists also recognize this condition.
If your preschool and grade school children have problems going to sleep, staying asleep or snore even once per week they should be evaluated.
Abstract Title: Indirect Effect of Tooth Grinding on Preschool Performance Presentation Date: Tuesday, June 10, 2017. Category: Pediatrics, Abstract ID: 0210, Updated Nov. 6, 2017
Over the past few years, I have seen a growing number of young women and girls with aggressive, degenerative arthritis in their TMJ joints. They didn’t have pain until the damage was late, usually a couple years after clicking started in their joint. Clicking in a TMJ means that the cartilage disc has torn off of the bone and no longer cushions the joint. Arthritis will start soon after. Typically it is wear and tear arthritis, but more recently I’ve seen the aggressive arthritis as mentioned in this study.
The study results align with my experience and more specifically targets juvenile idiopathic arthritis and its underdiagnoses. As the article reports, the TMJ diagnosis is often late because it’s rarely painful in the first 1-2 years.
The two hallmark signs that should prompt an evaluation are limited mouth opening (normal for all ages is the width of 4 fingers between the front teeth – or above 40-44mm open) and clicking in the jaw joint. Either sign should prompt a clinical and radiographic evaluation by an experienced TMJ specialist to assess for early signs of the degenerative joint disease.
The study recommends that to prevent lifelong orofacial complications, early recognition and treatment is important. The signs or symptoms in teenage and early adult females are changes in the bite, TMJ clicking or popping and/or pain in the TMJ area. Young girls seem to be more likely to have this condition, but males are also affected.
A clinical exam of the TMJ along with our high resolution, low dose i-cat 3-D imaging can show the early signs of degernative joint disease and clinical limitations that are associated with it. Decompressing the TMJ with orthotics is one of the most important interventions to arrest the disease. Additionally we would refer for JIA (juvenile idiopathic arthritis) testing in the event other joints might be at risk.